Clinical Documentation Improvement Specialist (CDIS)

Posting Number
# of Openings
Quality Management
Union Status
Non Union
Adirondack Medical Center
Saranac Lake

Position Summary

The role of the Clinical Documentation Coordinator is, at its core, that of an educator, who is able by virtue of exceptional interpersonal skills to successfully and pro-actively work with all members of the healthcare team to achieve the most timely and accurate patient record possible, prior to discharge.


The Clinical Documentation Improvement Specialist, in consultation with the HIM Director and others as appropriate and consistent with the AHA Coding Clinic, is responsible for daily concurrent review of inpatient medical records to identify opportunities for improving the quality of medical record documentation for reimbursement, severity of illness, and risk of mortality.  Opportunities include identification of cases where diagnoses and procedures are either absent, not stated in appropriate terminology, or are not appropriately recorded. Opportunities may also be identified through focused audits as requested by the CMO, CFO, AVP, or a service or specialty.


The CDIS interacts in a positive and productive manner on a daily basis with physicians and providers and other clinical professionals regarding documentation clarification, in accordance with prevailing guidelines published by the Association of Clinical Documentation Improvement Specialists (ACDIS).  The CDIS identifies cases for Physician Advisor intervention and coordinates the physician advisor reviews and educational opportunities with the medical staff. The CDIS collects statistics from the reviews and maintains accurate records of review activities (scorecard) to document cost/benefits and to identify patterns and trends affecting the case mix index. The CDIS's goal is to achieve a complete medical record by the time of patient discharge in order to facilitate the coding and DRG assignment process.

The CDIS ensures that all requirements and deadlines for the National Hospital Quality Measures (NHQM) are met to preserve the hospital’s Annual Market Basket Update; actively communicates in real time with and pro-actively educates nurses, physicians, providers and others regarding NHQM standards; provides regular progress reports to Core Measure Team and physicians, including reports of non-compliant cases; recommends and collaborates in the development of processes, policies, tools, order sets and forms that will facilitate core measures success; serves as the liaison to any core measures outsourcing vendor; participates in Meaningful Use activities; and assures that all databases, including dashboards, pay for performance reports and the OPPE log, reflect up to date NHQM data and action plans.


The CDIS meets with the AVP and/or CMO on at least a bi-weekly basis to provide updates on current activities; and will provide to the AVP at the end of each month a written summary of activities and plans of actions.

All employees of AMC are bound by the Mission, Vision, Employee Philosophy and must uphold the Guiding Principles of Compassionate, Accountable, Respectful, Exceptional Service



Current working knowledge of ICD-9-CM and ICD-10 coding principles and guidelines or willingness to obtain this knowledge within six months of hire required. Current working knowledge of MS-DRG’s and APR-DRG’s.
CCS Certification preferred; required within three years of hire. Minimum of 2 years acute care clinical experience required. Working knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding, and reimbursement required. RN with current New York State license preferred. Current working knowledge of the National Hospital Quality Measures required. Familiarity with pay for performance initiatives, meaningful use, and relevant third party, federal and state standards and regulations a plus, and will be required within six months of hire. Experience with electronic medical records required. Experience with MS-Office suite required.


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